CDC National Survey of maternity Care Practices in Infant Nutrition and Care (mPINC): Using State Reports to Inform, Influence, and Monitor Change Katherine Shealy, MPH, IBCLC, RLC Deborah Dee, PhD, MPH Division of Nutrition, Physical Activity and Obesity National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Atlanta, GA DNPAO Teleconference Slide 1 August 13, 2009 Improving Healthy Infant Care in Medical
I. CDC mPINC Survey background a. Rationale b. Survey development and implementation c. Survey findings II. Reporting mPINC findings Card a. Facility Benchmark Reports b. www.cdc.gov/mpinc c. CDC State Breastfeeding Report d. State mPINC Reports III. Utilizing the State mPINC Report efforts a. Collaboration across facilities b. Statewide collaborations c. Facility Quality Improvement
d. Research opportunities IV. Future plans Slide 3 a. Preparing for the 2009 mPINC Why target the maternity hospital stay? Public Health Impact In the US, >99% of births occur in hospitals: Characteristics of care are relatively consistent nationwide Length of stay Delivery of care The maternity stay is a time when new mothers have abundant access to health professionals. The focus is on preventive care: [in MOST instances] the goal is to maintain existing health of the infant and mother, totally different from other in-patient hospital populations who are sick
The first days of life are the most sensitive time for establishing Slidebreastfeeding. 4 Breastfeeding at 8 weeks Percent of mothers (interviewed at 8 wks postpartum about hospital experiences) (Murray et al., 2007) No Slide 5 Hospital Experience Yes 66 Breastfeeding in the 1st hour 77
65 No supplemented feeding 81 62 Rooming-in 74 69 No pacifiers 78 64 Phone number given to mothers
75 Approx mean diff = 12% Receiving commercial discharge packs increases likelihood to supplement within 10 weeks by 39%. (Oregon PRAMS) Slide 6 The number of supportive strategies that mothers experience predicts risk of breastfeeding cessation. Percent of mothers who breastfed < 6 weeks
30.0% Slide 7 26.9% (DiGirolamo et al., 2008) 21.5% 15.5% 0 Steps measured: Early bf initiation Exclusive breastfeeding Rooming-in On-demand feedings No pacifiers Information
1 2 provided 13.7% 6.2% 3.2% 3 4 5 Number of Baby-Friendly steps mothers reported experiencing 6 Hospital patients expect their medical care to be evidencebased. Patients expect care decisions to be based on what is necessary and beneficial to their
health. Assumptions: All procedures and practices work towards improving patient health outcomes Procedures and practices that undermine patient health outcomes are discouraged and take into account: Slide 8 Risk benefit ratio Extenuating circumstances Rare exceptions However, Some elements of maternity medical care, including processes, policies, and practices, routine practices, traditions,
habits, design, systems, and expectations can interfere with healthy infant care. Slide 9 maternity Practices in Infant Nutrition and Care Slide 10 What is the point of assessment and monitoring? Monitor progress Target problematic
practices Provide data for advocacy for change Enable performance benchmarking Improve maternity care practices Establish these practices as standard aspects of perinatal care Slide 11
Improve health outcomes for mothers What actually happens in maternity care settings? How common are positive practices? How common are negative practices? . Slide 12 Geographic variations?
Predictors of variations? Birth census Population served Staffing Others? mPINC Survey Concepts Practices and policies related to the WHO/ UNICEF Ten Steps to Successful Breastfeeding Labor and birthing practices such as: Induction & augmentation Mode of delivery Postpartum care practices such as: Slide 13
Infant location for routine procedures Methodology Biennial national census of facilities routinely providing maternity services Private hospitals Public hospitals Free-standing birth centers Single key informant Assesses usual practice among healthy, term newborns
Slide 14 Methodology 52 questions 36 of the questions were categorized into 7 dimensions of care. Points were assigned to responses to every question. Higher points were given for practices that are supportive of breastfeeding. Subscores = average of points for each question in the dimension. Composite quality practice scores = average of care dimension subscores. Slide 15
State Mean Composite Quality Scores (Quartiles), 2007 Slide 16 DC DC PR PR Typical maternity care in the US includes many types of problematic practices. Most practices are beyond the control of individual patients. Composite Mean, 63 76
79 70 66 59 51 40 Labor and Feeding of Breastfeeding Delivery Breastfed Care Infants Slide 17
Assistance MotherInfant Contact Discharge StaffTraining Structural & Care Org Aspects of Care Inappropriate practices are common, especially among surgical (cesarean) births. Percent of facilities agreeing Vaginal births Routine care for most mothers does not include skin-to-skin
contact with the infant. Less than half of breastfeeding patients begin breastfeeding within Slide 18 33.7% 1 hour 19.7% Surgical births 51.2% 2 hours 32% Mothers and babies are separated for many reasons, the cumulative effect may be problematic. Mother out of room
Pediatric rounds 60.3% 18.1% Change of shift Visiting hours Slide 19 3.4% Percent of facilities reporting each practice Receiving infant formula free of charge contradicts AMA policy recommendations and makes it more difficult to adhere to HACCP plans. No, 11.9% Yet 88% of facilities do it anyway. Does your facility
receive infant formula free of charge? Slide 20 Yes, 88.1% Almost three quarters of facilities provide infant formula samples to breastfeeding mothers. No, 27.4% Are discharge packs containing infant formula provided to breastfeeding mothers? Yes, 72.6% Slide 21
Benchmark Reports were mailed individually to specific people at each respondent facility. This multipurpose document is an intervention strategy developed to raise awareness, provide motivators for change, and identify barriers to change that are specific to the facility. The report is customized to each respondent and provides detailed survey information. Slide 22 The target audiences for the Benchmark Reports were very narrowly defined, and content was specifically tailored to meet audience needs. Hospital audience:
Slide 23 CEO/Administrator Director of Quality Improvement Director of Obstetrics Director of Pediatrics Mother Baby Nurse Manager Survey Recipient Birth Center audience: Birth Center Owner Medical Director Head Midwife
Key Informant Additional Reports of mPINC Findings: CDC State Breastfeeding Report Card Slide 24 www.cdc.gov/breastfeeding/data/ State mPINC reports provide each state with a targeted, concise, prioritized, action-oriented summary of their data Planned audience for each state AAP Chapters Breastfeeding Coalitions includes:
Hospital Associations Health Departments WIC Agencies Medicaid Programs Slide 25 Insurance Commissions 1. What is this
& who did it? Why 2. change maternity care? Whats going well? 3. Whats not? 4. Who 5. cares about breastfeeding? Slide 26 STATE 1. What is this?
STATE STATE OUTLINE 2. change maternity care? Why 3. cares about breastfeeding? Who Slide 27 4. Whats going well? Slide 28 5. Whats not?
Slide 29 Some positive policy elements are already widespread in most facilities. 92.5% of facilities include breastfeeding education as a routine element of their prenatal classes. 98.5% of facilities consistently ask about and record mothers infant feeding decisions. Slide 30 Almost 2/3 of facilities unnecessarily separate mothers and infants within the first 30 minutes of life. Are mother and baby
usually skinto-skin while staff are completing routine newborn procedures? Slide 31 Yes 38% No 62% NB: Routine newborn procedures include Apgar, foot printing, ID banding, etc. The most effective discharge care is also the rarest. 31.2% Return clinic visit Home visit
21.4% 54.9% Telephone call 40.9% Center support group 54.7% Referral to support group 71.3% LC referral 90.9% WIC referral Outpatient clinic referral 27.0%
93.8% Phone # given 79.3% List of resources Bfeeding assessment sheet Slide 32 51.5% Percent of facilities reporting each practice Staff breastfeeding training and competency assessment is inadequate, especially for new staff. New staffreceive <18 hours of breastfeeding 94.4%
training Existing staffreceive <5 hours of breastfeeding 75.6% training Few/some staffreceived any breastfeeding 40.7% education in last year Staffcompetencies assessed less than annually Slide 33 56.5%
Percent of facilities reporting each practice Who did this? 2&3. Why should we do something? 4&5. How does my state measure up? 6. What else did CDC find? Whats not? Slide 34 7. What can we do?
6. Slide 35 What else did CDC find? 7. What can we do? Slide 36 Central location for mPINC information: www.cdc.gov/mpinc Methodology General and Detailed Results Tables Downloadable files
Survey instruments (hospital and birth center versions) Sample Benchmark Report Information sheets on: Slide 37 Maternity care practices and breastfeeding General mPINC information mPINC dimensions of care Benchmark Reports State Example: Massachusetts
Roger Edwards, ScD Bouv College of Health Sciences Northeastern University [email protected] Slide 38 Safe and Healthy Beginnings is a pilot project of the AAP Quality Improvement Innovation Network through a partnership with the Center for Health Care Quality at Cincinnati Childrens Hospital Medical Center. The project was designed to ensure a safe and healthy beginning for all newborns by testing measures, strategies, and tools based on the key aspects of the revised AAP hyperbilirubinemia guideline, including 1) the assessment of a newborns risk for severe hyperbilirubinemia, 2) support for breastfeeding mothers, and 3) coordination of care between the newborn nursery and primary care
practicethe newborns medical home. As a result of this project, these tested tools are now available for widespread use. (http://www.aap.org/qualityimprovement/quiin/SHB.html) Ultimate Goal: Standard healthy infant nutrition and care ensures all mothers and babies receive care that utilizes best practices and Slide 41 is free of policies, practices, and environmental influences
that undermine maternal and child health and Many hands make light work CDC Romeo Christian Deborah Dee Ron Ergle Larry GrummerStrawn Renita Macaluso Carol MacGowan Paulette Murphy Ron Nuse Kelley Scanlon Andrea Sharma Katherine Shealy Thelma Sims Joanna Stettner Guijing Wang Battelle Jennifer Cohen Mary Kay Dugan Diane Manninen
Eileen Miles Slide 42 State Health Departments Mary Applegate (NY) Tina Cardarelli (IN) Jennifer Dellaport (CO) Ken Rosenberg (OR) Laurie Tiffin (CA) Rosanne Smith (VA) Sara Bonam Welge (NY) Breastfeeding Coalitions Kirsten Berggren Rachel Colchamiro Sarah Grosshuesch Becky Mannel Karen Peters Amelia Psmythe Kim Radtke Megan Renner
Professional Associations Lauren Barone (AAP) Edward Newton (ACOG) Hospital Practices Cinny Kittle (WV Hospital Karin Cadwell Assn) Debbi Heffern Patricia Underwood (ANA) Michael Lettera Robert Wiskind (AAP) Elaine Locke Universities/Med. Schools Anne Merewood Elizabeth Adams Carol Melcher Andrea Crivelli-Kovach Ann DiGirolamo Barbara Philipp Roger Edwards Molly Pessl Laurie Feldman-Winter Amy Spangler
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